Tissue manipulation

ABSTRACT

An apparatus and method for manipulating and anchoring tissue is provided. The invention is directed to solving the problem of manipulating and anchoring tissue within a joint when access to that tissue is limited, for example, during arthroscopic surgery.

This application is a continuation of application Ser. No. 08/048,922,filed Apr. 15, 1993, now U.S. Pat. Ser. No. 5,417,691, herebyincorporated by reference, which is a continuation of application Ser.No. 07/192,813, filed Apr. 20, 1988, abandoned, which is acontinuation-in-part of application Ser. No. 06/848,341, filed Apr. 4,1986, now U.S. Pat. Ser. No. 4,741,330, which is a continuation ofapplication Ser. No. 06/496,116, filed May 19, 1983, abandoned, which isa continuation-in-part of application Ser. No. 06/380,043, filed May 20,1982, now abandoned.

TECHNICAL FILED

This invention relates to an apparatus and method for manipulating andanchoring cartilage and similar fibrous tissue within a joint.

BACKGROUND ART

Conventional medical clamps have certain disadvantages when used formanipulating cartilage or other tissue within a joint duringarthroscopic surgery. Primarily, the clamps have a tendency to slip offthe cartilage. Additionally, the size of the clamps in relation to therelatively small space within the joint makes it difficult to maneuverother surgical instruments, such as a scalpel or arthroscope, within theconfined space of the joint. Such clamps can also interfere with theview of the inside of the joint afforded by the arthroscope. Since theclamps must be .introduced into the joint through an incision, they arelimited in their range of manipulation by the location of the incision.In order to apply a desired directional traction to the cartilage, itmay be necessary to release the clamp from the cartilage, reintroducethe clamp through another incision, and reclamp the cartilage.

It is often necessary to repair torn fibrous tissue, such as a ligamentor tendon, or reattach such tissue to bone. While in some instances itis possible to insert two needles into the joint and then thread both ofthem with a suture to form a loop to reattach torn parts of fibroustissue, that procedure is undesirable because it is complex andtime-consuming. The alternative of more radical arthrotomy is alsoundesirable because of the increased amount of trauma and resultantincreased morbidity encountered in the use of such a procedure.

As is explained in the following summary and description, the presentinvention provides a relatively compact and easy to use apparatus formanipulating cartilage and other fibrous tissue, and for anchoring thetissue to other tissue or to bone. Some technical references that may beof general interest are as follows: Allen, U.S. Pat. 3,699,969; Shein,U.S. Pat. 3,527,223; Woo, U.S. Pat. 3,943,932; Almen, U.S. Pat.3,500,820; Johnson et al., U.S. Pat. 3,871,368; and Smith, U.S. Pat.4,243,037. None of these references discloses a method or apparatussuitable for manipulating fibrous tissue during arthroscopic surgery, orfor effectively reattaching fibrous tissue to bone or to other fibroustissue.

Disclosure of Invention

The aforementioned problems associated with use of conventional medicalclamps for manipulating tissue are overcome by the present invention,which provides an apparatus and an associated method for manipulatingand anchoring tissue during arthroscopic surgery. The apparatus providesadequate fixation of the tissue during such surgery and minimallyinterferes with the use of other instruments within the joint.

The apparatus particularly comprises an elongated anchor member having asuture attached proximate the midpoint of its length. The anchor memberis inserted through the tissue with the suture extending therefrom toprovide a mechanism for manipulating the tissue within the joint. Theend faces of the anchor member may be slanted to facilitate movement ofthe anchor member through the tissue.

The preferred means of inserting the anchor member includes a hollowneedle having a sharp tip and an open butt. A hollow tube of equal orgreater length than the needle slides within the needle. A limitingmechanism is provided at the butt of the needle and at the correspondingportion of the hollow tube to selectively position the tube within theneedle so that the tube does not extend outwardly beyond the tip of theneedle.

The anchor member is located within the tip of the hollow needle ineither a deformed U shape, or in its normal, substantially straightshape. The suture extends from the anchor member through the bore of thetube.

A removable shield fits over the tip of the needle to prevent the sharptip from cutting the suture or the anchor member during the process ofinserting the anchor member into the hollow needle.

With the anchor member located within the tip of the needle, the needletip is inserted into a joint during a surgical procedure. The needle tippierces the tissue to be anchored and passes substantially through thetissue. The limiting mechanism is manipulated so that the tube may bepushed forward to the tip of the needle, thereby expelling the anchormember from the tip of the needle into or behind the piece of tissue tobe anchored. As the anchor member is expelled from the tip of the needleit assumes an orientation generally perpendicular to the length of thesuture. The needle and tube are then removed from the joint, leaving thesuture extending through the tissue and out of the joint. The tissue ismanipulated by the application of tension on the suture.

If it is desirable to push the tissue, the suture may be rethreaded orleft threaded in the tube and the tissue may then be securely heldbetween the tube and the anchor member by applying tension to thesuture. If it is desirable to control the tissue from a different angle,or through a different incision, a hook-ended instrument may be passedthrough another incision to hook the suture and pull the tissue. It willbe apparent that moving the tissue in this manner is possible withoutdetaching the anchor member from the tissue. If necessary, the tissuemay be removed from the joint by tension on the suture once the tissuehas been surgically freed from the joint.

It is often desirable to permanently reattach to bone fibrous tissue,such as tendons or ligaments. An alternative embodiment of a tissueanchoring apparatus is provided for that purpose. More particularly, theapparatus of this embodiment includes a deformable anchor member thathas a base and at least two legs. Each leg is attached to the base andextends therefrom to terminate in an outer end. A suture is attached tothe base of the anchor member. The anchor member is formed of resilientmaterial for urging the anchor member into a relaxed position whereinthe ends of the legs are spaced apart a maximum distance. The anchormember is deformable into a deformed position wherein the ends of thelegs are spaced apart a minimum distance that is less than the maximumdistance.

While in the deformed position, the anchor member is insertable into ahole that is drilled into the bone at the location the tissue is to beattached to the bone. The hole has a diameter that is less than themaximum distance between the ends of the anchor member legs.Consequently, upon insertion of the anchor member into the hole, theends of the anchor member legs bear, upon the bone within the hole, andthe suture extends from the hole. Whenever tension is applied to thesuture, the ends of the legs dig into the bone and resist removal of theanchor member from the hole.

With the anchor member anchored in the hole, the suture is available forsecuring the tissue to the bone. One way of using the suture to securethe tissue to the bone is to attach a retainer to the suture forpressing the tissue against the bone. The retainer includes resilientsuture-engaging edges and corners, and is slidable along the suture inone direction, but grips the suture to resist sliding in the oppositedirection. The retainer thereby holds tissue against the bone duringhealing so that the tissue will properly reattach to the bone.

To avoid prolonged irritation of surrounding tissues, the anchor member,suture, and retainer of the present invention may be made of materialthat is gradually absorbable by the body.

The foregoing and other features of the invention will be more readilyunderstood upon consideration of the following detailed description ofthe invention, taken in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an elevational view of an apparatus for manipulating andanchoring tissue according to the present invention, with a portion ofthe apparatus sectionally cut away.

FIG. 2 is a sectional elevational view of the apparatus shown in FIG. 1,illustrating the manner of deformably lodging an anchor member withinthe tip of a hollow needle.

FIG. 3 is a fragmentary, sectional elevational view of the apparatus ofFIG. 1, showing the apparatus piercing cartilage.

FIG. 4 is a fragmentary, sectional elevational view of the apparatus ofFIG. 1, illustrating the manner of expelling the anchor member betweencartilage and bone.

FIG. 5 is a sectional elevational view of the apparatus of FIG. 1,showing cartilage secured by the anchor member and suture components ofthe apparatus.

FIG. 6 is an enlarged perspective view of the anchor member and suture,showing the normal and deformed configuration of the anchor member.

FIG. 7 is a foreshortened perspective view of a hook-ended instrumentusable with the apparatus of FIG. 1.

FIG. 8 is a sectional elevational view of an apparatus for manipulatingand anchoring tissue, illustrating an alternative manner of lodging theanchor member within the tip of the needle.

FIG. 9 is a sectional elevational view of the apparatus shown in FIG. 8,illustrating expulsion of the anchor member from the tip of the needle.

FIG. 10 is a perspective view of the inner surface and an edge of aretainer used in association with the suture and the anchor member forsecuring tissue to bone or to other tissue.

FIG. 11 is a perspective view of the outer surface and an edge of theretainer shown in FIG. 10.

FIG. 12 is a perspective view of an alternative retainer.

FIG. 13 illustrates a portion of a joint in which the anchor member,suture, and retainer are used to connect and retain a piece of cartilagein position against another piece of cartilage from which it had beentorn.

FIG. 14 is a sectional view taken along line 14-14 of FIG. 13.

FIG. 15 is a side elevational view, partly in section, of an anchormember and suture that can be anchored to a bone.

FIG. 16 is a sectional elevational view of the anchor member and sutureof FIG. 15, positioned within the preferred mechanism for inserting theanchor member into a hole in a bone.

FIG. 17 is a sectional elevational view showing the anchor member ofFIG. 16 anchored within a hole in a bone and used, in conjunction withthe suture and a retainer, to hold tissue against the bone.

FIG. 18 is a sectional elevational view showing an alternative method ofusing an anchor member and suture to hold tissue against the bone.

FIG. 19 is a side cross-sectional view of an alternative embodiment ofan anchor member that has a hole formed therethrough to permit a sutureto be looped through it.

FIG. 20 is a cross-sectional view of another alternative embodiment ofan anchor member that can be anchored to a bone.

FIG. 21 is .a top view of the anchor member of FIG. 20.

Modes for Carrying out the Invention

One preferred embodiment of the present invention, shown assembled inFIGS. 1 and 2, provides a resiliently deformable anchor member 10, whichis attached to a suture 12 and adapted to fit deformably within the tip26 of a hollow needle 14. A hollow tube 16, also adapted to fit withinthe needle 14, is used to expel the anchor member from the tip 26 of theneedle after the needle has pierced a piece of fibrous tissue, such asthe cartilage 18, as shown in FIGS. 3 and 4. Once expelled between thecartilage 18 and bone 38, the anchor member resiliently resumes itsnormal shape, as shown in FIG. 5. The anchor member of the inventionmight also be used to secure ligament or tendon, as will be describedhereinafter, and the term tissue will be broadly used herein toencompass cartilage, tendons, ligaments and similar tissue.

The anchor member 10, shown in perspective view in FIG. 6, is anelongated cylindrical member. The anchor member 10 has end faces 20 and22,at the respective extremities thereof. The end faces 20 and 22 areslanted relative to the longitudinal axis of the anchor member andpreferably lie in respective planes that intersect one another. Thesuture 12 is attached to the anchor member 10 at a location 24 betweenthe end faces 20 and 22. The suture 12 may be attached to the anchormember 10 during formation of the anchor member.

The anchor member 10 is preferably comprised of a resilient materialsuch as a plastic. As a result, the anchor member is capable of beingdeformed from its relaxed, straight shape into a U-shape as shown inbroken line in FIG. 6. Although the anchor member is shown to have acircular cross-section, other cross-sectional shapes could be utilizedwithout departing from the principles of this invention.

The anchor member 10 is formed with sufficient rigidity to cause it toresist deformation under moderate pressure, but not so rigid as toprohibit the U-shaped deformation when the anchor member is lodgedwithin the needle as shown in FIGS. 2 and 3. The material comprising theanchor member has sufficient elasticity to restore the anchor membersubstantially to its relaxed, straight configuration shown in FIGS. 1,4, 5 and 6.

The needle 14 shown in FIGS. 1 and 2 has a hollow cylindrical shape witha sharp-edged open tip 26, an open butt 27, and a bore extendinglongitudinally therethrough from the tip 26 to the butt 27. The sharptip 26 is beveled to create a sharp edge at its outer circumference andis thereby adapted to pierce and penetrate tissue. Alternatively, thesharp tip 26 could be beveled to create a sharp edge at its innercircumference.

An annular collar 28, which includes an open keyway 30 formed therein,encircles the butt of the needle. The keyway extends a short distancetoward the needle tip through the cylindrical wall of the needle asshown in FIG. 2.

The hollow tube 16, which is at least as long as the needle 14, and hasan elongate cylindrical shape with an open tip 17 and an open butt 19,is adapted to slide within the hollow needle. The tube 16 has aninterior bore diameter large enough to receive the suture 12therethrough so that the free end 13 of the suture extends from the openbutt 19 of the tube. The tube 16 has an annular flange 32 encircling thebutt 19 thereof to prevent the tube, when pushed toward the needle tip26, from protruding more than a predetermined distance beyond the tip.The tube is preferably such a length that when the flange 32 ispositioned immediately adjacent the collar 28, the tip 17 of the tube isproximate the needle tip 26,.as shown in FIG. 4.

A limiting mechanism for controlling movement of the tube 16 is providedin the form of a key 34 that is mounted on the outer cylindrical wall ofthe tube 16. The key 34 is adapted to mate with the keyway 30 associatedwith the needle 14. The key 34 will prevent, the tip 17 of the tube 16from moving proximal to the tip 26 of the needle 14 unless the key 34 isaligned with the keyway 30. This alignment is accomplished by rotationof the tube 16 within the needle 14. If the tube 16 is of theaforementioned preferred length, the key 34 should be located closeenough to the tip 17 of the tube 16 to permit the anchor member 10 to befully drawn into the needle tip 26 when the tube is positioned insidethe needle with the key and keyway out of alignment, as shown in FIGS. 2and 3. As will be apparent, the keyway 30 should be of sufficient lengthto allow the flange 32 to contact the collar 28 when the key 34 ispositioned in the keyway 30. It should be recognized that, while theaforedescribed key and keyway arrangement is believed to be particularlysuitable, other mechanisms for limiting the movement of the tube 16within the needle 14 could be utilized without departing from theprinciples of this invention.

As shown in FIGS. 1 and 2, a shield 36 having a generally cylindricalshape with open ends is adapted to fit removably on the sharp needle tip26. The inner walls of the shield have three distinct sections: an uppersection 29, an intermediate section 31, and a lower section 33. Theupper section 29 is cylindrical and has an inner diameter substantiallyequal to the outer diameter of the needle tip 26 so as to permit theshield to be mounted over the tip 26. The intermediate section 31 iscylindrical and has an inner diameter slightly smaller than the outerdiameter of the needle tip 26, to shield the anchor member from thesharp edge of the needle tip 26. The lower section 33 has a bell-likeflared shape to encourage appropriate deformation of the anchor member10 as it is drawn into the needle tip 26 as shown in FIG. 2.

Prior to use, the apparatus is first assembled as shown in FIGS. 1 and2, the shield 36 being mounted upon the tip 26 prior to the suture 12being threaded through the tube 16 so that the free end 13 protrudes outthe butt end 19 of the tube. Tension on the free end 13 of the suture 12will pull the anchor member 10 into the needle tip 26 as shown in FIG.2, the inner surface of the bell-shaped lower section 31 of the shieldguiding the anchor member into the appropriate U-shape, the anchormember being protected from the sharp tip by the shield 36.

The tube 16 is axially positioned within the needle with the key 34abutting the collar 28 so that there is appropriate space for the anchormember to lodge deformably within the needle tip 26. Positioning thetube 16 within the needle as shown in FIGS. 1 and 2 is not necessaryprior to introducing the free end 13 of the suture 12 into and throughthe bore of the needle 14, but having the tube so positioned when theanchor member 10 is drawn into the tip 26 is helpful to ensure that theanchor member 10 is not positioned an unnecessary distance from theneedle tip 26. Once the anchor member 10 is deformably lodged in the tip26, the shield 36 may be removed.

The assembled apparatus may then be introduced into the joint of apatient, either through an incision or by using the needle tip 26 topierce the skin and surrounding tissue. The tip 26 of the needle 14 isthereafter used to pierce-the cartilage 18 which is to be manipulated oranchored, as shown in FIG. 3.

Once the tip 26 has pierced the cartilage 18, the tube 16 may be axiallyrotated within the needle 14 so that the key 34 aligns with the keyway30. The tube 16 may then be pushed toward the tip 26 of the needle 14,the key 34 entering the keyway 30, and the tip 17 of the tube 16expelling the anchor member 10 from the needle, tip 26 as shown in FIG.4. As the anchor member 10 is pushed from the needle tip 26, it resumesits normal elongated shape. Where the cartilage 18 is very near bone 38,the slanted end faces 20, 22 of the anchor member facilitate movement ofthe longitudinal extremities of the anchor member through the space 40between the bone 38 and cartilage 18.

Once the anchor member 10 has generally resumed its normal elongateshape behind the cartilage 18, the needle 14.and the tube 16.may bewithdrawn from the joint, allowing the cartilage 18 to partiallycollapse around the anchor member 10 and suture 12 as shown in FIG. 5.The suture 12 is now anchored to the cartilage 18, and the cartilage maybe securely held and manipulated by tension on the suture 12 tofacilitate further surgical procedures on and around the cartilage.

The relatively small size of the suture 12 allows virtually unobstructedvision of the interior of the joint through an arthroscope, and alsopermits the insertion of other surgical instruments, such as anarthroscope or scalpel, through the same incision as the suture. Due tothe flexibility of the suture 12, tension may be applied from manydirections as dictated by the needs of the surgical process. Furthercontrol of the cartilage 18 is available by rethreading the suture 12through the tube 16 and applying tension to the suture, therebyeffectively clamping the cartilage 18 between the anchor member 10 andthe tip 17 of the tube 16, and allowing the cartilage to be pushed,rather than pulled, into a desired position.

A hook-ended instrument 42, shown in FIG. 7, may be used to achieve evengreater maneuverability of the anchored cartilage 18 by introducing theinstrument 42 into the joint through a separate incision., capturing thesuture 12 in the hooked end of the instrument, and drawing the suture 12out of the joint through such other incision. The cartilage may then bemanipulated and controlled in the manner described above, through adifferent incision, without detaching the anchor member 10 from theanchored cartilage 18.

If necessary, the anchored cartilage 18 may be surgically freed, andremoved from the joint by tension on the suture 12.

Referring now to FIGS. 8 and 9, an anchor member 50, which is similar tothe anchor member 10 described above, has fixedly attached thereto asuture 52. The anchor member 50 is held within the tip 53 of a hollowneedle 54, ahead of the tip 56 of a hollow tube 55. The edge of thehollow needle 54 at the tip 53 is formed in a plane that is slantedrelative to the longitudinal axis of the needle, thereby to form a sharpleading edge 51 for piercing tissue. The free end 57 of the suture 52extends from the hollow tube 55.

As shown in FIGS. 8 and 9, the anchor member 50 may be used inessentially the same fashion as is the anchor member 10, with the hollowneedle 54 piercing a piece of fibrous tissue, such as cartilage 60. Theanchor member 50 is expelled from the tip 53 of the hollow needle 54 asthe hollow tube 55 is slid toward the tip 53 of the hollow needle 54.The anchor member 50 thereafter assumes a position between the cartilage60 and a bone 62, where it extends generally perpendicular to the suture52. The slanted end faces 64, 65 of the anchor member 50 assist indirecting the anchor member 50 to this position. Once the anchor member50 has been expelled from the needle 54, the suture 52 is pulledoutwardly to move the anchor member 50 to the position shown in brokenline in FIG. 9, where it extends laterally along the lower surface ofthe cartilage 60.

It is noteworthy that the anchor member 50 depicted in FIGS. 8 and 9 maybe formed of substantially rigid material. A rigid anchor member can beinserted into the space between the cartilage and bone by moving theneedle 54 so that it is inclined to the bone surface and then expellingthe anchor member from the needle.

A rigid anchor member may be lodged within cartilage or other tissue(i.e., as opposed to being inserted between cartilage and bone) byexpelling the anchor member substantially straight into the tissue andpulling on the suture. Because the suture-is attached between the endsof the anchor member, tension on the suture tends to-rotate the anchormember into a position substantially perpendicular to the suture,thereby causing the anchor member to become firmly lodged within thetissue. In this regard, rotational movement of the anchor member 50 intoa position substantially perpendicular to the suture 52 most readilyoccurs when the end face 65 that last enters the tissue is slanted sothat a force applied perpendicular to that surface (that force being acomponent of the reaction force of the tissue against the surface 65 astension is applied to the suture of the expelled anchor member) tends tomove that face 65 of the anchor member 50 away from the suture 52. Thispreferred slanting of the end face 65 is shown in FIGS. 8 and 9.

Referring now to FIGS. 10-14, retainer devices 68 and 69, each having apair of generally parallel surfaces, are made of resilient material andhave slits 70 and 72, respectively, which intersect near the centralpoints of the parallel surfaces, defining pointed corner flaps 71 and73, respectively. The retainers 68 and 69 are preferably circularbecause the circular shape may reduce the possibility of irritation ofsurrounding tissue. It will be understood, however, that this shape is amatter of choice and that other shapes would also be acceptable.

Raised points 74 are provided on the inner surface of the retainer 68 tobear against tissue, and to assist in immobilizing the tissue while theanchor member is in use. In many instances, however, the raised points74 will not be required and a flat inner surface will suffice. Thefollowing discussion of retainer use is directed to the anchor member 50of FIG. 8; however, it is understood that the discussion applies to allembodiments of the anchor member described herein.

The retainer 68 (or retainer 69) may be used in conjunction with theanchor member 50 by inserting the free end 57 of the suture through theretainer at the intersection of the slits 70 after the hollow needle andhollow tube have been withdrawn from around the suture. When the suture52 is inserted through the retainer 68, the flaps 71 that are definedbetween adjacent slits 70 are resiliently deformed toward the directionof movement of the suture therethrough. Thereafter, the flaps wedgeagainst the suture 52 and resist withdrawal of the suture through theslits. By applying tension to the suture 52 (see FIGS. 13 and 14) andurging the retainer 68 along the suture to the surface of cartilage 76from which the suture extends, the retainer may be used to maintaintension in the suture, thereby holding a loose piece of cartilage 76against the stable piece of cartilage 78 from which the loose piece ofcartilage 76 had been torn or fractured.

The anchor member 50, suture 52, and retainer 68 may be left permanentlyin the joint to retain the torn cartilage 76 in its proper locationagainst the stable cartilage 78, with the retainer 68 resting againstthe outside of the stable cartilage 78, between the surface of thestable cartilage 78 and muscle tissue 79 adjacent thereto.

It is noteworthy that in many instances the needle 54 may be insertedinto a joint from opposing directions. For example, the anchor member 50was deposited in the position shown in FIGS. 13 and 14 by a needle thatpenetrated the muscle tissue 79. The needle could have been insertedfrom the opposing side of the joint (and not through muscle tissue 79)to deposit the anchor member 50 in the position occupied by the retainer68 in FIGS. 13 and 14. Accordingly, the positions of the anchor member50 and the retainer 68 would be reversed from those shown in FIGS. 13and 14, but the loose cartilage 76 would still be held against thesecure cartilage 78. One reason for inserting the needle from theopposing side of the joint, as just explained, would be to avoiddamaging any nerves or blood vessels that are present in the region ofthe muscle tissue 79.

To prevent prolonged irritation of the surrounding tissue by thepresence of the anchor member 50 and retainer 68, it is particularlydesirable to form the anchor member and retainer of material that can begradually absorbed by the body of the patient as healing occurs.Resilient, synthetic materials that are gradually absorbable by the bodyare known for use in sutures and are desirable as materials for theanchor member and retainers of the present invention. One such materialis an absorbable polymer known as poly-diaxanone (PDS), which isavailable from Ethicon, Inc., of Summerville, New Jersey.

Referring now to FIGS. 15-17, an anchor member 80 is particularlyadapted for use in anchoring a suture 82 to bone 96 so that the suture82 may be used to reattach tissue 98 to the bone. The anchor member 80is generally bullet-shaped having a rounded convex base 84 with twoattached legs 86 extending from the base. The outer ends 85 of the legsare tapered and terminate in sharp outer edges 87. The anchor member 80is formed of resilient material, and whenever the anchor member is inits relaxed state (FIG. 15), the legs 86 diverge outwardly so that theouter edges 87 of the legs are spaced apart a maximum distance D. Oneend of a suture 82 is embedded within, or otherwise attached to, thebase 84 of the anchor member 80. Suture 82 extends outwardly from thebase 84 between the legs 86.

Preferably, the outer surface of the anchor member 80 carries aplurality of barbs 88. The barbs 88 point outwardly, and away from therounded convex base 84. As a result, the exposed sharp point of eachbarb 88 is directed generally toward the direction in which the suture82 extends away from the base 84 of the anchor member 80.

As shown in FIG. 16, the anchor member 80 is inserted within the tip 93of a hollow needle 90 ahead of the tip 91 of a tube 92 that is used toexpel the anchor member 80 from the needle. The suture 82 extendsthrough the bore of the tube 92.

The anchor member 80 and the bore of the needle 90 are sized so that theanchor member is in a deformed position whenever it is lodged within thetip 93 of the needle. In the deformed position, the legs 86 of theanchor member are pressed together with the outer edges 87 of the legsbeing spaced apart a minimum distance d corresponding to the needle borediameter. This distance d is less than the maximum distance D betweenthe outer edges 87 as measured when the anchor member is in the relaxedposition (FIG. 15).

As noted, the anchor member 80 is formed of resilient material.Consequently, whenever the anchor member 80 is expelled from the needle90, the intrinsic resilience of the anchor member urges it into therelaxed position. As will now be explained, the tendency of the anchormember 80 to move from the deformed into the relaxed position provides asimple mechanism for anchoring the anchor member 80 in bone so that, inconjunction with the attached suture, there is provided a means forreattaching tissue to the bone to promote healing.

More particularly, with reference to FIG. 17, a hole 100 is drilled intothe bone 96 in the region where the tissue 98 is to be reattached to thebone. The hole diameter is less than the maximum distance D between theouter edges 87 of the anchor member, but greater than or equal to thebore diameter of the needle 90. With the anchor member 80 within the tip93 of the needle 90, the tissue 98 is pierced by the needle in a manneras described earlier. The tip 93 of the needle is forced through thetissue 98 and then aligned with the hole 100. Next, the anchor member 80is expelled from the needle into the hole 100 by sliding the tube 92toward the tip 93 of the needle 90 as described earlier with respect toFIGS. 3-5.

Once expelled from the needle 90 into the hole 100, the resilience ofthe anchor member 80 urges the outer edges 87 of the legs 86 to bearupon the bone within the hole 100. With the outer edges 87 of the legsbearing upon the bone, any tension applied to the suture 82 causes thesharp edges 87 to dig into the bone to secure the anchor member withinthe hole. The barbs 88 also dig into the bone to supplement theanchoring effect of the legs 86.

Preferably, the anchor member 80 is sized so that when it is positionedwithin the hole 100, the outer edges 87 of the legs 86 are beneath arelatively dense bone layer 97 that is located at the surface of thebone 96, and is known as the cortical layer 97. As a result, tension inthe suture (in conjunction with the intrinsic resilient force of theanchor member 80 that forces the leg edges 87 apart) tends to lodge theedges 87 of the anchor member beneath the cortical layer 97, renderingthe anchor member substantially irremovable from the hole 100.

As shown in FIG. 17, a retainer 68, as described earlier, may beemployed with the suture 82 to secure the tissue 98 to the bone 96.

FIG. 18 illustrates another technique for securing tissue 99 to the bone96, wherein two anchor members 80 are anchored in holes 101, 103, andthe free ends of the sutures 82 are tied together over the tissue.

It is noted that it may not be necessary to first pierce the tissue 99before depositing the anchor member 80 into the hole 101, 103. Forinstance, the anchor member 80 may be deposited within the hole 101, 103in the manner described above., and the free end of the suture 82 may bethreaded through a conventional surgical needle that is used to piercethe tissue. The surgical needle is then removed and the free ends of thesutures 82 are secured as described above.

FIG. 19 depicts an alternative embodiment of an anchor member 110suitable for anchoring in bone. The anchor member 110 is substantiallysimilar to the anchor member 80 described earlier, except that itincludes a continuous passage 112 formed therein to pass into one leg114, through the base 116, and out the other leg 115. The suture 118 isthreaded through the hole passage 112 so that two suture segments 120extend from the anchor member. This configuration of the anchor member110 allows the user to select any type of suture for use with the anchormember 110, depending upon the particular surgical needs. Further,having two suture segments 120 available for securing the tissue to thebone is often desirable. For example, whenever an odd number of anchormembers 116 is used, the resulting even number of available suturesegments 120 permits each segment of one anchor member to be tied to acorresponding segment of an adjacent anchor member, without the need fortying more than two suture segments together.

FIGS. 20 and 21 illustrate a side sectional view and top view,respectively, of another alternative embodiment of an anchor member 130formed in accordance with this invention. This embodiment is a generallycup-shaped piece of resilient material, such as plastic, having a base132 with four legs 134 extending upwardly therefrom. The sharp outeredge 136 of each leg is spaced apart from an opposing edge 136 by amaximum distance D whenever the anchor member is in the relaxed positionas shown in FIG. 20. As noted earlier, distance D is greater than thediameter of the hole into which the anchor member 130 is deposited.Preferably, two holes 138 are formed in the base 132 of the anchormember 130. A suture 140 is threaded through the holes 138.

The anchor member 130 is deposited within a hole in a bone in a mannersimilar to that explained with respect to the apparatus of FIG. 16.Specifically, the anchor member 130 is positioned within the tip of ahollow needle (not shown) where it assumes a deformed position. In thedeformed position, the outer edge 136 of each leg is held near the outeredge 136 of the opposing leg a distance d that is less than the“relaxed” distance D and corresponds to the diameter of the needle borein which the anchor member is lodged. When the anchor member 130 isexpelled from the needle and deposited within the hole in the bone, theintrinsic resilience of the anchor member 130 forces the outer edges 136against the bone, thereby anchoring the anchor member within the hole.The suture 140 is thereafter available to secure tissue against the boneas discussed above.

The anchor members 80, 110, 130 just described may be formed of materialthat is absorbable by the body. Alternatively, the anchor members may beformed of non-absorbable material (e.g., stainless steel of suitableresilience) that remains in the bone indefinitely.

The terms and expressions that have been employed in the foregoingspecification are used herein as terms of description and not oflimitation, and there is no intention, in the use of such terms andexpressions, of excluding equivalents of the features shown anddescribed or portions thereof, it being recognized that the scope of theinvention is defined and limited only by the claims that follow.

1. An apparatus for insertion into and through tissue to provide amechanism for manipulating and anchoring tissue within a patient, theapparatus comprising: an elongated anchor member having opposite endsthat are tapered to be insertable into and through the tissue to bemanipulated, the member being shaped to normally assume a substantiallystraight configuration; and a suture irremovably attached to the anchormember between the opposite ends of the anchor member, the suture havingan end free for manipulating the tissue into which the anchor member isinserted, the suture being flaccid in the vicinity of the anchor memberso that the suture and anchor member do not assume a predeterminedrelative orientation.
 2. The apparatus of claim 1 wherein the suture isa flexible, non-stiffened member in the vicinity of the anchor member.3. The apparatus of claim 1 wherein the anchor member is resilientlydeformable.
 4. The apparatus of claim 1 wherein the tapered ends of theanchor member define slanted end faces.
 5. The apparatus of claim 1wherein the suture is attached to facilitate substantially perpendicularextension of the suture from the anchor member.
 6. The apparatus ofclaim 1 wherein the suture is attached to the anchor member mediallythereof and extends laterally away from said elongated anchor member. 7.The apparatus of claim 1 wherein the anchor member is insertable throughthe tissue to be manipulated by the suture to a position underneath thetissue and the suture extends therefrom to outside of the tissue.
 8. Theapparatus of claim 1 wherein the suture and anchor member are configuredsuch that the end of the suture is free for manipulating the anchormember to thereby manipulate the tissue.
 9. The apparatus of claim 1wherein the free end of the suture is a first end and the suture alsohas a second end, which second end is fixed to the anchor member, andwherein the anchor member is insertable to a manipulation positionunderneath the tissue that is thereafter to be manipulated, and whereinin the manipulation position, the first end is outside the tissue andthe second end is underneath the tissue.
 10. The apparatus of claim 1wherein the suture and anchor member have a manipulation position inwhich the anchor member is substantially entirely underneath the tissueto be manipulated.
 11. The apparatus of claim 1 wherein the anchormember is attached to the suture near the longitudinal midpoint of theanchor member and the suture extends laterally therefrom.
 12. Theapparatus of claim 1 further comprising a second anchor member attachedto the suture.
 13. The apparatus of claim 12 wherein the second anchormember is slidingly attached to the suture.
 14. The apparatus of claim12 wherein the anchor members have different shapes.
 15. The apparatusof claim 12 wherein the suture is flaccid in the vicinity of the secondanchor member so that the suture and the second anchor member do notassume a predetermined orientation.
 16. The apparatus of claim 12wherein the suture is attached to facilitate substantially perpendicularextension of the suture from each anchor member.
 17. A method,comprising: advancing an elongate member to place the elongate memberrelative to a first body structure of a patient, placing a flat,circular member relative to a second body structure of the patient witha flat surface of the circular member against the second body structure,the two members being coupled by a flexible member, the circular memberbeing slidable along the flexible member, applying tension to theflexible member while sliding the circular member along the flexiblemember, the circular member acting to maintain tension on the flexiblemember, and rotating the elongate member from a position substantiallyparallel to the flexible member during advancement of the elongatemember to a position substantially perpendicular to the flexible member.18. The method of claim 17 wherein the elongate member is rotated bypulling the flexible member.
 19. The method of claim 17 wherein the twomembers are coupled by suture.
 20. The method of claim 17 wherein thecircular member is slid by urging the circular member along the flexiblemember.
 21. The method of claim 17 wherein the flexible member isreceived through an opening in the circular member.
 22. An apparatus forinsertion into and through tissue to provide a mechanism formanipulating and anchoring tissue within a patient, the apparatuscomprising: an elongated anchor member having a substantiallycylindrical shape with opposite ends, the member having a first lengthalong a first side and second length that is shorter than the firstlength along a second side that is opposite to the first side such thatends of the second side are axially spaced from ends of the first side,the member being shaped to normally assume a substantially straightconfiguration; and a suture irremovably attached to the anchor memberbetween the opposite ends of the anchor member, the suture having an endfree for manipulating the tissue into which the anchor member isinserted, the suture being flaccid in the vicinity of the anchor memberso that the suture and anchor member do not assume a predeterminedrelative orientation.
 23. The apparatus of claim 22 wherein the sutureis a flexible, non-stiffened member in the vicinity of the anchormember.
 24. The apparatus of claim 22 wherein the anchor member isresiliently deformable.
 25. The apparatus of claim 22 wherein the endsof the anchor member are tapered and define slanted end faces.
 26. Theapparatus of claim 22 wherein the suture is attached to facilitatesubstantially perpendicular extension of the suture from the anchormember.
 27. The apparatus of claim 22 wherein the suture is attached tothe anchor member medially thereof and extends laterally away from saidelongated anchor member.
 28. The apparatus of claim 22 wherein theanchor member is insertable through the tissue to be manipulated by thesuture to a position underneath the tissue and the suture extendstherefrom to outside of the tissue.
 29. The apparatus of claim 22wherein the suture and anchor member are configured such that the end ofthe suture is free for manipulating the anchor member to therebymanipulate the tissue.
 30. The apparatus of claim 22 wherein the freeend of the suture is a first end and the suture also has a second end,which second end is fixed to the anchor member, and wherein the anchormember is insertable to a manipulation position underneath the tissuethat is thereafter to be manipulated, and wherein in the manipulationposition, the first end is outside the tissue and the second end isunderneath the tissue.
 31. The apparatus of claim 22 wherein the sutureand anchor member have a manipulation position in which the anchormember is substantially entirely underneath the tissue to bemanipulated.
 32. The apparatus of claim 22 wherein the anchor member isattached to the suture near the longitudinal midpoint of the anchormember and the suture extends laterally therefrom.
 33. The apparatus ofclaim 22 further comprising a second anchor member attached to thesuture.
 34. The apparatus of claim 33 wherein the second anchor memberis slidingly attached to the suture.
 35. The apparatus of claim 33wherein the anchor members have different shapes.
 36. The apparatus ofclaim 33 wherein the suture is flaccid in the vicinity of the secondanchor member so that the suture and the second anchor member do notassume a predetermined orientation.
 37. The apparatus of claim 33wherein the suture is attached to facilitate substantially perpendicularextension of the suture from each anchor member.
 38. A method,comprising: advancing a first member into and through tissue in apatient, the first member being elongated and shaped to normally assumea substantially straight configuration and having a suture attachedthereto between the opposite ends of the first member, the suture havingan end free for manipulating the tissue into which the first member isinserted, the suture being flaccid in the vicinity of the first memberso that the suture and member do not assume a predetermined relativeorientation, rotating the first member from a position substantiallyparallel to the suture during advancement of the first member to aposition substantially perpendicular to the suture, placing the firstmember at a first location within the patient, placing a second memberat a second location within the patient, the two members being coupledby the suture, the second member being slidable along the suture, andapplying tension to the free end of the suture, the length of the suturebetween the first and second members being shortened with the first andsecond members tending to be drawn together.
 39. The method of claim 38wherein the tissue comprises stable cartilage and torn cartilage, andfurther comprising: advancing the first member such that the sutureextends from the stable cartilage to the torn cartilage, and applyingsufficient tension to the suture to retain the torn cartilage againstthe stable cartilage.
 40. The method of claim 38 wherein the free end ofthe suture is a first end and the suture also has a second end, whichsecond end is fixed to the first member, and further comprisinginserting the first member to a manipulation position underneath thetissue that is thereafter to be manipulated.
 41. The method of claim 38wherein the first member is rotated by pulling the suture.
 42. Themethod of claim 38 wherein the second member is placed after the firstmember.
 43. A method, comprising: advancing an elongate member to placethe elongate member relative to a first body structure of a patient,placing a flat member relative to a second body structure of thepatient, the two members being coupled by a flexible member, the flatmember being slidable along the flexible member, applying tension to theflexible member while sliding the flat member along the flexible member,the flat member acting to maintain tension on the flexible member, androtating the elongate member from a position substantially parallel tothe flexible member during advancement of the elongate member to aposition substantially perpendicular to the flexible member.
 44. Themethod of claim 43 wherein the elongate member is rotated by pulling theflexible member.
 45. The method of claim 43 wherein the two members arecoupled by suture.
 46. The method of claim 43 wherein the flat member isslid by urging the flat member along the flexible member.
 47. The methodof claim 43 wherein the flexible member is received through an openingin the flat member.